What is a normal bowel habit ?

People vary a lot in how often they open their bowels - usually between three times a day and three times a week in the U.K. A stool should be solid, but moist and easy to pass.

What does the bowel do ?

	Receives food and liquid we eat and drink.
	Absorbs most of the nutrients from food and drink into the blood-stream.
	Secretes fluid from the body into the gut.
	Propels its contents from the stomach down the length of the bowel to the back passage (anus).
	Excretes waste material as stool.

What is constipation ?

	A person is constipated when fewer than 3 bowel actions happen in a week, or if there is often a need to strain to pass a stool.
	Constipation is not a disease. Occasionally, however, it can be a symptom of underlying disease.
	Constipation is hardly ever harmful. You won’t become ‘poisoned’ or ‘dirty’ if your bowels don’t open.

How does constipation trouble people ?

You may feel uncomfortable or distended (bloated) in the abdomen, or feel a sense of fullness above the back passage. Straining can lead to piles which may appear at the anus or bleed. Women may find intercourse uncomfortable if the bowel is very full.

What causes the usual types of constipation ?

	Diet - usually a lack of fibre (roughage) in the diet.
	Bad bowel habits - most people have an urge to go to the toilet once or twice a day. This often happens after a meal. If this urge is ignored, the stool dries out and becomes hard. The next bowel movement may then be difficult or painful.
	Unco-ordinated straining. Some people do not strain effectively and/or fail to relax the muscles around the back passage when they strain.

Constipation can be made worse by:

	dehydration: low fluid levels in the body
	inactivity
	emotional upsets
	a painful anal condition such as piles
	shift work
	poor toilet facilities.

What conditions can cause constipation ?

Constipation can be caused by:

	obstruction to the bowels by scarring, inflammation or tumours
	pregnancy
	underactive thyroid gland
	altered function in the nerves or muscles controlling bowel movement such as in the irritable bowel syndrome (see separate DDF leaflet).

Which medicines cause constipation ?

It is common to become constipated without realising that it is due to the medicines you are taking, eg:

	antacids which contain aluminium or calcium taken for indigestion
	iron tablets (sometimes)
	some pain-killers such as codeine
	cough medicines which also contain codeine
	‘nerve’ treatments - some antidepressant drugs - certain tranquillisers
	drugs given to affect muscle function such as some given for abdominal pain, bladder relaxation or parkinsonism.

What is fibre and how does it help ?

	Fibre is found not only in the tough fibrous part of fruit and vegetables, particularly in the stalk and on the outside of fruits, seeds or grains (bran is the outer covering of wheat grains), but also in soft parts of fruit and vegetables that are not digested by the small intestine.
	Much of the food we eat is digested in the stomach and small intestine, but fibre is not digested and passes to the large intestine (colon). Here it: - acts like blotting paper, drawing water into the stool - increases the number of bacteria in the colon.

Both these effects make the stool larger, softer and easier to pass.

How can you increase the fibre in your diet ?

The easiest way to improve your diet is to eat brown, wholemeal bread and plenty of fresh fruit and vegetables. If this is insufficient, a good way to further increase fibre is to sprinkle one or two tablespoons of bran on breakfast cereal. A dietitian can advise you and several books about high fibre diets are available at book stores.

What should you do if your bowels are not regular ?

	Always try to go to the toilet as soon as you feel the urge.
	Try to do this as a routine, eg. as soon as you get up, or after breakfast.
	Drink at least 4 pints of fluid daily.
	Eat an adequate amount of fibre in your diet.
	Be as active as possible even if you have a disability.
	Avoid laxatives.
	Eat regularly.
	Ensure good toilet facilities at home and work.

When you should see your doctor ?

If constipation is not responding to the simple treatments outlined and is causing you trouble.

Sudden or gradual changes in bowel habit, occurring for no obvious reason in people aged approximately forty years or more, should be reported to the doctor (especially if there is rectal bleeding or new abdominal symptoms such as pain or distension).

Will I need any tests for constipation ?

	Probably not, although your doctor may want to take a blood sample to make sure your thyroid gland is working properly.
	If your constipation is very bad, your doctor may wish to check whether the colon is normal by arranging: - a barium enema X-Ray (this involves the insertion into the rectum of a harmless material which shows up on an X-ray, allowing the doctor to see any abnormalities) or - a flexible sigmoidoscopy or colonoscopy (inserting a flexible telescope so the doctor can see the whole of the colon).
	Tests are sometimes done to check the function of the muscles around the back passage.
	If you suddenly become constipated for no reason, you should see your doctor promptly.

Are laxatives harmful ?

	Constipation is usually improved by a proper diet, and drugs are therefore not needed. Occasional use of a suitable laxative is harmless, but regular use may make you dependent on it.
	Stimulant laxatives, such as senna and cascara, cause changes in the colon if used regularly for many years but can be useful every now and then for a short time.
	Laxatives cause gripey abdominal pains if used in large doses.

Which laxatives can I use ?

A few people will need to take laxatives regularly, but this should only be done on your doctor’s advice. The best types are:

	Bulk laxatives - concentrated fibre preparations are helpful for those who find it hard to change their diet. These include: - bran - ispaghula husk - methylcellulose - sterculia The above preparations should always be taken with plenty of water.
	Stimulant laxatives - Bisacodyl, Senna.
	Osmotic laxatives - mineral salts (eg. magnesium sulphate/Epsom salts, magnesium citrate, magnesium hydroxide) - retain water in the bowel. The stool is then softened.
	Lactulose, lactitol or sorbitol-sugars which humans can’t digest. They act a bit like fibre and a bit like an osmotic laxative.
	Suppositories inserted into the rectum which soften the stool and stimulate bowel action.
	Enemas - a few people, especially those with severe nerve damage in the spine, have to use enemas.

With any laxative, it is important to keep up a good fluid intake with extra drinks if necessary.

Are other treatments available ?

Special tests may show that straining is unco-ordinated. Such people may be helped by training to effectively contract their abdominal muscles and relax those around the back passage. This training can be supplemented by a device which enables a person to tell if their muscle is relaxed (biofeedback), but such a device is often not necessary. This treatment is, at present, limited to a few centres, but is likely to become more generally available.

If constipation is associated with emotional problems, counselling or similar treatment may help.

A few sufferers require surgical treatment, but this is reserved for those with a definite abnormality of the large intestine.

Constipation in childhood

This condition differs in some respects from that in adults. See our special leaflet for this topic.

Summary

1.	A tendency to constipation should usually be managed by:
	developing regular bowel habits a good intake of fibre and fluids exercise.
	Bulk-forming or osmotic laxatives are preferable to stimulant laxatives which should be taken regularly only under medical supervision. Very severe constipation (which tends to occur in younger women despite the measures described above) may need specialist help.
2.	If you are constipated, this does NOT mean that bodily wastes are being absorbed and damaging your health.
3.	Sudden or gradual changes in bowel habit, occurring for no obvious reason in people aged approximately forty years or more, should be reported to the doctor (especially if there is rectal bleeding or new abdominal symptoms such as pain or distension).

The need for research

We need research to help adult patients whose constipation does not respond to dietary fibre, fluids and exercise, and who are greatly troubled by abdominal pain and discomfort.

The Digestive Disorders Foundation has supported pioneer research into treatment of constipation by muscle training. Further research is needed into the causes and treatment of constipation in childhood. This can cause great disability and distress to sufferers and their families.

The DDF is the only charity concerned with the whole digestive system and relies entirely on the support of people like you.